HomeMy WebLinkAboutRural Water Refund Request
The personal information collected on this form is protected by the privacy provisions of the Freedom of Information & Protection of Privacy Act (FOIPP
Act) of Alberta and will be used for the administration of programs and delivery of services by the County of Newell (FOIPP A ct Section 33(c)). If you have
any questions about the collection of this informati on, contact the FOIP Coordinator, County of Newell, Box 130, Brooks, AB T1R 1B2 by phone at 403-
362-3266 or e-mail at administration@newellmail.ca.
RURAL WATER REFUND APPLICATION FORM
Landowners will be notified if the application is denied. Deadline for submission is on September 30, 2022.
Original Registration Date: ______________________________
Landowner Name __________________________________________________________________________
Mailing Address: ___________________________________________________________________________
City : _______________________ Province: __________ Postal Code: ____________________________
Phone Number:_____________________________ Alternate Phone Number: _________________________
Email Address: ____________________________________________________________________________
Legal Land
Description:
W4M
Quarter Section Township Range Meridian
Municipal
Address:
House ID Access Number Road Name
if applicable
_____________________________________ ___________________________________
Print Name Signature
For Office Use Only
Date Received: ___________________________
Roll Number: _____________________________ Refund Approved: _______________________________
Approved By: ____________________________ Date Approved: _________________________________
Comments/Notes: __________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________